BROOKLYN 2 RADIOTHERAPY Carl ROWBOTTOM

NZIMRT: Hamilton Sep 2013

BROOKLYN 2

RADIOTHERAPY

Carl ROWBOTTOM

Sat 31st Aug 2013

Session 2 / Talk 3

11:15 – 12:00

ABSTRACTRadiotherapy is part of the care package for 40% of patients cured of their cancer; it is a cost effective and safe form of treatment. This is in large part due to the safety conscious culture embedded within radiotherapy services. When considering innovation the radiotherapy environment can often be negatively seen as a risk-averse culture with clear barriers to progress. The Demings approach to statistical and quality control can be used to ensure quality, improve productivity and introduce innovation safely within a radiotherapy environment. The approach was applied to increasing IMRT provision for patients treated at The Christie, the largest radiotherapy centre in the UK, where levels of IMRT were increased from <5% in 2007 to >35% in 2012. Examples will be given of the use of clear objectives, decision rules, feedback and statistical measurements during the project and continuing in routine practice. It is hoped that repeated application of the principles of the Demings approach will improve the timely uptake of innovations within radiotherapy in the future.

The Christie NHS Foundation TrustNZIMRT: Hamilton 31st Aug 2013

Innovation in a safety conscious culture

Dr Carl RowbottomRadiotherapy Physics Group Leader

The Christie NHS Foundation Trust, Manchester


The Christie

• One of only 3 specialist cancer hospitals in England

• One of the largest radiotherapy services in Europe • Serves population of 3.2 million people• 16 linacs on 3 sites (12:2:2)


Innovation and a safety conscious culture?

• How do we introduce innovation within the radiotherapy environment?• Resistance to change

• Ensuring safety of innovation

• Diffusion of innovation theory• Standardization – Edwards Deming systems

thinking

• Increasing IMRT provision at The Christie as a case study........


How can we apply diffusion of innovation theory & systems

thinking to improve IMRT provision?


Diffusion of Innovations

• Everett Rogers describes theory to describe how, why and at what rate new ideas/technology spread through cultures.....



• There are 5 stages in the decision innovation process• Knowledge – individual exposed to an innovation, lacks information

about innovation

• Persuasion – individual interested in the innovation and seeks information

• Decision – Individual weighs advantages/disadvantages of using the innovation

• Implementation – Individual employs the innovation to a varying degree

• Confirmation – individual finalizes decision to continue using innovation.



• There are strategies to help diffusion......• Innovation adopted by a highly respected individual

within a social network• Create desire for a specific innovation• Find early adopters to use innovation• Provide positive reactions and benefits for early

adopters on innovation• Benefits to patients• Benefits to staff


Edwards Deming – Systems Thinking

• ‘If you can’t describe what you are doing as a process, you don’t know what you are doing.’

• Key ideas• Understand sources of variation, work on consistency• Use statistical process control to distinguish between

different types of variability• Perpetuate a cycle of continuous quality improvement




Edwards Deming

• ‘To discuss bringing in to a more desirable state an organization whose objectives, and the necessary and appropriate limitations and constraints, are really not stated is to take on an impossible task.’

• ‘The aim of leadership is not merely to find and record failures of men, but to remove the causes of failure: to help people to do a better job with less effort.’


IMRT expansion as an example of Innovation in a Safety Critical

Environment


The Vision

• Establish a comprehensive intensity modulated radiotherapy service at The Christie

• With the capacity to offer the treatment to all patients who would benefit from this advanced form of radiotherapy


Motivation for the Vision

• Position at The Christie in 2008:• Quota for small number of intensity modulated

radiotherapy treatments established in 2006

• Quotas set to provide a limited service amounting to ~3% of radical treatments (~20-25% would benefit)

• 100 patients received intensity modulated radiotherapy compared to ~1000 who would benefit.

• National picture in 2008:• 2% of radical patients treated with Intensity Modulated

Radiotherapy1

1. Williams MV, Cooper T, Mackay R, Staffurth J, Routsis D, Burnet N. ‘The implementation of intensity-modulated radiotherapy in the UK’, Clinical Oncology, 22;623-628 (2010)


IMRT position @ The Christie in 2008

• Local barriers to increased provision• Small numbers each month make it difficult to gain

sufficient familiarity in the process• Background knowledge of staff (IMRT not included

in any major training scheme).

• Other perceived barriers to IMRT• Linac time & resources for patient QA• Patient throughput (cf conformal treatments?)• Oncologist time for outlining• Familiarity with the process/ Lack of confidence


Adoption of Innovation Phase

• Focus on training initial core team of physicists and planning radiographers to meet future demand (Early adopters)

• Concentrated training & development (theoretical & practical)• (Knowledge / Persuasion)

• Focus on improved quality of treatment for the patient• (Persuasion / Decision)

• Regular feedback to staff regarding progress• (Implementation / Confirmation)


Moving forwards

• New IMRT planning room established in Jan 2009• 2 planning radiographers + 2 physicists• Co-ordinating outlining, planning, verification,

treatment of IMRT patients only• (early adopters / implementation phase of

adoption)• Increasing targets for number of patients per

month

• Protocols & SOPs for majority of IMRT treatments• (Standardization / Consistency)


Moving forwards

• Comprehensive training programme for staff (early majority / late majority)• Background teaching• Practice case studies• Supervised learning

• (Persuasion stage of adoption for early/late majority)

• Quality Management System (QMS) sign-off• (Standardization / Consistency)

Early Adopters - IMRT Central The Christie in 2009


Perceived barriers to IMRT

• Local barriers to increased provision• Small numbers each month make it difficult to gain

sufficient familiarity in the process• Background knowledge of staff (IMRT not included

in any major training scheme).

• Other perceived barriers to IMRT• Linac time & resources for patient QA• Patient throughput (cf conformal treatments?)• Oncologist time for outlining• Familiarity with the process/ Lack of confidence


Will patient specific IMRT/VMAT QA limit capacity?


Verification will limit IMRT/VMAT Capacity

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Target

• Eventually >95 verifications per month needed. • >100 in 2013 (120 inverse planned IMRT/VMAT

treatment plans in July 2013)


Options for verification?

• Scale up resources to achieve verification for all inverse planned treatments• Will resources be available?• Could resource be better utilised?

• Batch verifications and perform within first 3 days of treatment• What if days 1-3 are incorrect?

• Don’t verify all treatment plans• How do we decide what not to verify?• What other measures do we put in place?


Edwards Deming

• ‘Routine inspection becomes unreliable through boredom and fatigue’

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Total Verifs

Total Plans


I’M Really Tired IMRT


Verification: Results outside tolerance

• Error Rates (since Jan 2009)• Prostate (414 patients - 2090 beams)

• Dose difference issue - 10 beams (0.5%)• Gamma Analysis issue - 14 beams (0.7%)

• H&N (707 patients - 5021 beams)• Dose difference issue - 1 beam (0.02%)• Gamma Analysis issue - 4 beams (0.08%)

• Number of plans changed due to verification... 2!(from over 1000 patients!)


Build quality in to the process

• Technical staff tend to advocate for all patients (Standardization)

• Oncologists tend to advocate for individual patients (Personalization)

• Personalization can interfere with the goals of Standardization


• Uncertainties affect outcomes.......


What approach would you prefer?


What would Edwards Deming say?

• ‘Quality comes not from inspection, but from improvement of the production process. Inspection, scrap, downgrading, and rework are not corrective action on the process’

• ‘Putting out fires is not improvement of the process’

• ‘Inspection to improve quality is too late, ineffective, and costly’

• ‘What is needed are operational definitions of what is acceptable and what is not’



• Follow standard methodology for treatment site whenever possible.........• Clinical site protocol• Standard operating procedures • IMRT/VMAT class solutions (with suggestions for

modifications when required)• Agreed assessment forms• Checklists (planning + checking)• Operational definitions / plan metrics• Rejection codes


Clinical Site Protocols

• Clinical site protocols provide basis for clear operational definitions.

• Should include Scanning Outlining Dose limits Roles/Responsibilities QA

• Need to be reviewed after first cohort of patients completed


Operational definitions: Initial Class Solution

• Clinical site protocols provide basis for a TP class solution

• PTVs, OARs and dummy structures• Beam orientations• Inverse plan optimisation parameters

• Hints for what to do when class solution doesn’t give a good enough solution for an individual patient

Standardised using Pinnacle Scripts

Described in quality management system


Knowing when to stop – what is good enough?

• Why is it important to clearly know when to stop trying to improve the plan?Efficiency means more patients planned with IMRT for

same effortReduces variation in acceptable plansReduces waste from rejecting plans (often late in the

process)Saves your sanity


What approach would you prefer?


How do we know when the IMRT/VMAT plan is good enough?

Operational definitions: Agreed assessment values (autoforms)

• From the class solution create clear assessment values can be automatically generated & quickly evaluated from the TPS– If the plan meets the

assessment values and the distribution and DVHs look ‘normal’ then the plan is acceptable.


How do we know that the plan is ‘normal’?

Plan Metrics


• A multi-criteria score (MCS) based on distance between adjacent leaf positions, overall area of the field and beam-weight developed to determine good and bad constructions of the intensity modulation in a plan


How do we reduce variations?

How do we reduce re-work?


Operational definitions: Checklists

• Useful to reduce common errors produced by the system of work– Limit to less than 10, preferably less than 5.

– Wherever possible produce an active rather than passive response.

• Used extensively in aviation & surgery (See Gawande’s book for further details)



Operational definitions: Recording plan rejections to feed in to

improvement cycle

• How well do you understand the system?• How well have you been trained?• Do you know whether you are doing a good job?• How do you compare to your peers?


The improvement cycle – reducing variation

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Plan Rejections Sept - Dec 12

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Quality System improvement cycle• Clinical Site ProtocolClinical requirements of the oncologistsClear definitions of acceptable doses

• Class Solution Best starting set of parameters to achieve the

clinical site protocol Tips for adaptation when class solution fails

• Operational Definitions Clearly defined Work Instructions Automated planning/assessment wherever

possible Agreed assessment (pass/fail) Checklist to reduce common failure modes

• Errors/Rejection Codes Agreed list of reasons for rejection

• Review of clinical site protocol =>

class solution changes

• Review of class solution => operational

definition changes

• Review of operational

definitions => error/rejection code

changes

• Review of errors/rejection

codes => operational definitions


Does it work in practice?• Have we seen an increase in the number of patients

we are able to treat with IMRT?

• 100 patients treated with IMRT in 2008• 339 patients treated with IMRT in 2009• 569 patients treated with IMRT in 2010• 865 patients treated with IMRT in 2011• 1048 patients treated with IMRT in 2012• ~1200 patients in 2013?




Workload & Stressors in Clinical Radiation Oncology

• Mazur et al (IJROBP, 2012; 83(5):e571-576) used assessed workload in Clinical Oncology using the NASA Task-Load Index (TLX)• 173 workload assessments across multi-professional workforce• (Overall TLX score <35 low workload; >55 high workload)

• Found an association between workload & frequency of reported radiotherapy incidents.

• Typically there are 3-5 stressors per cycle of analysed tasks• Interruptions (41.4%), time factors (17%), technical factors

(13.6%), teamwork issues (11.6%), patient factors (9%), environmental factors (7.4%)




In Summary…….

• Think about the 5 stages in the diffusion of innovation process• Knowledge, Persuasion, Decision, Implementation,

Confirmation

• Be clear in setting the objectives • state goals & limitations

• Build quality in to the process• inspection is too late & inefficient

• Define operational standards ..... what is acceptable and what is not (reduce variation)

• Work to improve the system


Finally ..... remember

‘True genius resides in the capacity for evaluation of uncertain, hazardous, and conflicting information’

Winston Churchill

‘The difference between stupidity and genius is that genius has its limits’

Albert Einstein

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BROOKLYN 2 RADIOTHERAPY Carl ROWBOTTOM